Human beings do not start their own life. Do they have the right to invite a doctor to end it? The pros and cons of doctor-assisted suicide

IN MARCH, Australia's government overturned the world's first “right-to-die” law ever put into operation. Under the law, four terminally ill cancer patients in the country's Northern Territory had committed suicide with a doctor's help. In April, the United States Congress voted to forbid the use of federal money for doctor-assisted suicide. Last week, Oregon's senate voted to hold a second referendum on that state's euthanasia law, passed by a narrow majority of Oregon's voters in 1994, to ask if they now want to repeal it. The federal Supreme Court is about to hand down its decision on whether to overturn two of the country's lower courts and uphold two states' bans—in New York and Washington—on doctor-assisted suicide.

By comparison with this, the recent decision by Colombia's Supreme Court, which made Colombia the only country in the Americas to legalise euthanasia, looked like a vain attempt to swim against the tide. Yet the argument about whether people have the right to ask for help in ending their lives is far from over.

Throughout the ages, people have argued that killing yourself is a logical thing to do when faced with unbearable suffering. Under King Edgar, an English ruler of the tenth century, suicide was not penalised (by the confiscation of the suicide's property) if the deed was done because of ill-health or insanity. Sir Thomas More, a devout Roman Catholic of the 16th century, argued in his “Utopia” that the terminally ill should be helped from life by a doctor, and that the doctor should be absolved from either legal or moral blame. Early in the present century euthanasia bills were introduced, unsuccessfully, in legislatures in a number of western countries. But now that people are living longer—and frequently dying slowly, usually in hospital and often alone, from lingering and agonising diseases such as cancer—the debate has taken on a new urgency.

It is still deeply divisive. In the cases now before the Supreme Court of the United States, “friends-of-the-court” briefs were filed for both sides of the argument by an astounding array of people—politicians, doctors, religious organisations, women's groups, even a “dream team” of well-known philosophers (in favour of doctor-aided suicide). The subject is, understandably, fraught with legal and philosophical complexities. At the core of it, however, are three questions. First, do human beings have a right to decide how and when they will die? Second, if they do, does this include a right to have help in implementing that decision? And, third, if it does, is it possible to write legislation that will protect those who are old and sick, or chronically disabled, but who do not want to die?

A self-evident truth

No matter how zealously you drink your orange juice, eat your fruit and vegetables, organise your sleep and do your exercises, the fact remains that one day you will be dead. The only question—though, given current medical technologies, by no means a trivial one—is when. The present controversy rages around the notion that you should be able to decide this for yourself, especially if you find yourself in the advanced stages of an apparently soon-to-be-fatal illness.

The first and deepest objection comes from those who believe in God. Many religions hold that you have a duty to live until you die a natural death: that your life is not yours to dispose of. This was once a common justification for prohibiting any form of suicide. Nowadays, however, in many countries, it is not considered to be enough to form a basis of law.

The main non-religious objections stem from the belief, held by many people, that it is irrational to want to commit suicide. In someone bent on suicide, it is argued, depression or mental illness—or even excruciating pain—must be interfering with the making of a rational choice.

In many places, not least in America, such assumptions have led to laws that permit the forcible prevention of suicide. In the state of New York, if you announce that you propose to starve yourself to death, you will be force-fed. In California, attempted suicide gets you three days inside a mental hospital. It has even been suggested that America's current debate over doctor-assisted suicide is largely a symptom of the failure of the medical establishment to deal adequately with the pain of the terminally ill. According to a study published by America's Institute of Medicine on June 4th, most Americans do not have proper access to long-term palliative care, and a third die in pain that could be eased. Improve those figures, it is said, and there will be fewer requests for assisted suicide.

But none of this proves that the desire to die is always irrational, or that giving even total relief from pain to those who need it would remove all requests for help in dying. Roughly three-quarters of all dying Americans expire in hospitals or nursing homes, often helpless, stuck full of tubes, perhaps made unconscious so that they will not dislodge the tubes by moving their bodies. Even people who are in no pain may prefer to avoid this by dying at home, in private, in peace and with dignity. The question remains: Does it follow that they are entitled to a doctor's help in doing so?

Take 50 to die

At this point, some distinctions need to be made. First, the difference between doctor-assisted suicide and euthanasia. Doctor-assisted suicide is usually if not universally taken to mean that the doctor provides the knowhow and the means to commit suicide, but the patient is the one who actually takes the pills or pulls the trigger, with or without the doctor's presence. Philip Nitschke, an Australian doctor, provides patients with a machine hooked up to a laptop computer; the patient, following the instructions on the screen, is injected with lethal drugs. In voluntary euthanasia, however, the doctor kills a patient who has asked to die. In involuntary euthanasia, a doctor kills a patient who has not asked to die. In many circumstances, this is otherwise known as murder.

The debate over doctor-assisted suicide currently applies only to those who are terminally ill but are not on life-support machines. This is the result of another frequently made distinction, the one between “active” and “passive” euthanasia.

Passive euthanasia—switching off respirators or other life-support machines—happens in hospitals all the time. If someone is being kept alive by machines, he can ask that the treatment be withdrawn, even if that means he will certainly die. Most religious believers do not object to this: they see it as life coming naturally to its end. So passive euthanasia is not technically defined as assisted suicide. In most places it is now sanctioned by legislators and widely practised by doctors (though difficulties still arise if the patient is comatose and cannot say what he wants).

But there is also active euthanasia—the prescription or administration of drugs to someone who is not on a life-support system. Doctors have admitted, when asked, that they have given assistance to patients who wanted to die. How frequently they do so is not easy to discover: in most countries, this is a crime.

Between these two forms of euthanasia lies the murky legal area of “double effect” and its more grisly cousin, “terminal sedation”. If a doctor prescribes or administers pain-killing drugs in large doses, the result may well be that the patient dies. But so long as the doctor's intention was to relieve pain, no wrong has been done in the eyes of the law. If, on the other hand, the prescription reads “Take 50 to die”, the doctor is guilty of incitement to commit suicide, usually a punishable crime. In terminal sedation, a patient consents to be sedated into a coma (again with the intention of relieving pain), and to have his life-support withdrawn; the patient is allowed to starve to death, a process that may take some days.

Although many doctors defend this distinction, advocates of doctor-assisted suicide (including some doctors) argue that it is arbitrary and unfair. If a passer-by walked into a hospital off the street and started switching off the life-support machines of patients, he would be prosecuted for murder, rather than forgiven for allowing a natural process to take its course, even when his victims were genuinely moribund. Switching off a life-support machine is as efficiently death-producing as administering a fatal dose of a drug. Moreover, proponents of doctor-aided suicide say, a terminally ill patient should not have to choose between refusing food and water (and so starving and dehydrating to death) and waiting for the final indignity of being attached to a life-support machine.

Standing or sliding

The two main arguments against being helped into death, assuming you accept the morality of it, are both of the “slippery slope” sort. The first is that it is hard to know where the boundary lies. Should a patient be three days, three months or three years away from death when the help is given? If the criterion is that a patient should be terminally ill, how should “terminally” be defined? Is it logical to distinguish between terminally ill and chronically ill, if a chronically ill person wants to die but may have years to live? Should people in good physical health but emotional distress be allowed help in dying? This is a matter of where to draw the line.

The even tougher counter-argument is that the whole process is dangerously— some say catastrophically—open to abuse. To many, legal doctor-assisted suicide is a harbinger of evil, the start of a slide into a time of state-condoned euthanasia when the frail and the handicapped will be bullied into dying prematurely, doctors will become executioners, and the terminally ill will be offered the “treatment” of death instead of relief from pain.

Death, after all, is cheaper than treatment. It is not hard to imagine health-insurance companies and managed-care organisations agreeing to pay for barbiturates that kill rather than pills that merely reduce pain. Walter Dellinger, the acting solicitor-general of the United States, told the Supreme Court that managed-care organisations in Oregon have already offered to pay for death rather than long-term care.

The strongest practical argument the defenders of a ban on doctor-assisted suicide can make is that, though some people would benefit from help in dying, a greater number are vulnerable to potential abuse from such a system; therefore, society has an interest in asking the state to protect their lives. The trouble is that this argument leaves dying people preserved in a state of suffering without any chance to choose oblivion instead. Even more important, it assumes that a law for doctor-assisted suicide cannot be drafted in a way that would prevent its abuse.

Consider the Dutch

In principle, it should be possible to solve all these difficulties—to write legislation that protects the vulnerable, forbids insurance companies from paying for death but stinting on pain killers, and regulates the system of supervision. Unfortunately, there is not much practical experience to draw on. Only one country, the Netherlands, has had much experience in attempting to regulate the procedure of assisted death. Understandably, the results of the Dutch experience have come under intense scrutiny, and both sides of the debate claim the backing of what they find there.

In the Netherlands, euthanasia is technically illegal. Nevertheless, doctors who follow strict guidelines—which include making sure the patient really does want to die—have for the past two decades been protected from prosecution if they perform mercy-killings. Last November two reports published in the New England Journal of Medicine, and supported by an editorial, reviewed the state of the system in the Netherlands in 1995 and compared it with the results of a similar review conducted five years earlier. More than 500 doctors were interviewed, and questionnaires were sent to another 6,000 or so. The aim was to see whether a look at the Dutch experiment supports the slippery-slope arguments.

On the whole, the researchers were sanguine. Although the number of deaths from euthanasia had risen, they said, the increase was slight, and had been expected, and there was no evidence of abuse or careless decision-making. Although too many euthanasia deaths still go unreported, they added, the arrangements for supervision were good and getting better.

It was found that, in general, Dutch doctors receive a large number of requests for help in dying, 8,900 in 1990 and 9,700 in 1995. But they respond to only some of these. In 1990, about 1.7% of all deaths in the country were from active voluntary euthanasia; in 1995, the figure was 2.4% (see chart). Far fewer were from doctor-assisted suicide, 0.2% in both years. This may be due to the fact that the Dutch seem to regard euthanasia as the more humane option, since it ensures that death will come more swiftly. Grey-area deaths—administering pain-killers in large doses—stayed roughly the same, at about 19% of all deaths, and deaths arising from the decision to forgo treatment increased from around 18% to just over 20%. In most cases, the doctors estimated that life had been shortened by less than a week.

The Dutch researchers make two other interesting points. First, pain is not a particularly significant factor in leading people to ask for death: in the Netherlands, only 5% of requests for assisted suicide or euthanasia come from those who described themselves as being in unbearable pain.

Second, the fear that the old and frail will be bullied into committing suicide may be exaggerated. Euthanasia among those over the age of 80 does occur, but it is rare. Most Dutch people who opt for suicide are cancer patients between 55 and 75.

One result of the Dutch study is potentially alarming, however. In 1990, 0.8% of all deaths were deliberately brought about by doctors without the patient's request at the time, and in 1995 the figure was 0.7%. The researchers account for this by explaining that such deaths occur almost entirely because the patient has become what doctors call “incompetent” (permanently comatose) or because the patient suddenly deteriorates, to the point of being unable to say what he wants. But a commentary on the Dutch data, published in the Journal of the American Medical Association on June 4th, paints a distinctly more disturbing picture.

According to its authors (one of whom is medical director of the American Foundation for Suicide Prevention), both slippery slopes have already been slid down. They argue that the definition of those eligible for help in dying in the Netherlands has been broadened to include the chronically ill and, most recently, the emotionally distressed. And they claim that an increasing number of doctors are deliberately ending the lives of their patients without the patients' consent. The anecdotal evidence is sometimes chilling: “It could have taken her another week before she died. I just needed the bed.” Worse, the researchers believe that in some cases death has come to be regarded as a form of treatment, and patients are given little or no other choice. They cite, for instance, a woman who told her ageing husband to commit suicide or go into a nursing home. The man opted for suicide, and his doctor killed him.

This is sinister stuff. It is made no less worrying by the fact that, if euthanasia occurs without a request at the time by the patient, the patient is often described as incompetent. There are serious difficulties if the patient passes into the condition called incompetence without having said what he or she wants to happen.

Of course, such horror stories can be found wherever there are doctors, hospitals and dying patients. And the data suggest that most Dutch doctors are careful. The most recent results—published this week in the New England Journal of Medicine—show that, although psychiatrists in the Netherlands are frequently asked for help in dying by their patients, they rarely comply. Each year, only between two and five assisted deaths occur in patients with mental disorders, most of them people also nearing the end of a physical illness.

Still, the fact that scary things happen suggests that more regulation is needed. So what additional safeguards could be put in place? Waiting periods, second opinions and evaluations by psychiatrists are all part of the legislation being considered in other countries (see article). The patient should have to make an active request for death, signing a form saying clearly that this is what he wants. A formal, legal distinction between euthanasia and doctor-assisted death would also help. The doctor-assisted sort would leave the time and place of death to the patient. In the end, he might never commit suicide; but at least he would have known that he could have done so if he wanted.

Famous last words

For centuries, the decision of whether a doctor should help someone to die was a private matter between doctor and patient. Legislation neither explicitly forbade it (except in so far as it forbade murder) nor enshrined it as a right. To many people, this is where things should best be left.

Unfortunately, perhaps, that will not work. The advances of modern medical science have irrevocably changed the picture of death. Once upon a time, when your heart stopped, that was that. Now, you may well be revivable. Particularly in the United States, where malpractice suits abound and hospitals fight families who wish life-support to be withdrawn from comatose relatives, this has led to a medical culture where life is prolonged at all costs—provided you can afford it.

As a consequence, in the United States, many old people are subjected to futile treatments that diminish the quality of their life without greatly lengthening it. In America, fewer than 20% of deaths occur at home. In the Netherlands, the figure is over 40%. Moreover, in the Netherlands more people are likely to reject treatments if they think that the end of their life is near. Nowadays doctors want to be sure that if they follow a patient's wishes and help him to die they will not be prosecuted. Patients want to be sure that they will not be temporarily cured or revived against their wishes, only to die in another few weeks after unnecessarily prolonged misery. After all, although death is usually seen as a medical failure, it is eventually inevitable.

A year ago, it seemed as if the so-called right-to-die movement had gathered an inevitable momentum, and that doctor-assisted suicide would soon be written into law in many places. Now, things are less clear. If America's Supreme Court does not accept the argument that there is a constitutional right to choose one's time of death, the battle in that country will be fought out state by state. Expect especially fierce fights in Oregon between now and November, when that state's re-referendum is due. In Australia, too, referendums are expected to happen in a number of states in the next few years. Colombia's legislation has yet to be written; Japan, where a recent local court decision argued that euthanasia is not a crime, faces questions of ensuring consent in a medical environment where few patients are told they are terminally ill.

However, in the end such battles may prove mere skirmishes. The underlying problem remains. As medical science advances, the world's population is getting older. According to a paper published in this week's issue of Nature, in the next 50 years the proportion of the earth's population over the age of 60 will double. At the same time, resources for health-care will become increasingly stretched. Formal health-care rationing will add to the case for passive euthanasia: expensive medical care will be withheld from those who want it and need it if they are unlikely to live for much longer.

This may shift the balance away from unnecessary medical intervention and towards ensuring that the end of life is as comfortable and peaceful as possible. No doubt, the balance will be struck in different ways at different times in different countries. Meanwhile, rest in peace.